Painful Foot and Ankle American Association of Electrodiagnostic Medicine Tracy A. Park, MD David R. Del Toro, MD Mohammad A. Saeed, MD, MS Atul T. Patel, MD, MHSA Mark E. Easley, MD 2004 AAEM COURSE C AAEM 51st Annual Scientific Meeting Savannah, Georgia Painful Foot and Ankle Tracy A. Park, MD David R. Del Toro, MD Mohammad A. Saeed, MD, MS Atul T. Patel, MD, MHSA Mark E. Easley, MD 2004 COURSE C AAEM 51st Annual Scientific Meeting Savannah, Georgia Copyright © November 2004 American Association of Electrodiagnostic Medicine 421 First Avenue SW, Suite 300 East Rochester, MN 55902 PRINTED BY JOHNSON PRINTING COMPANY, INC. ii Painful Foot and Ankle Faculty Tracy A. Park, MD Mohammad A. Saeed, MD, MS Physiatrist Clinical Associate Professor Medical Rehabilitation Associates Department of Rehabilitation Medicine Milwaukee, Wisconsin University of Washington Dr. Park is currently in private practice at Medical Rehabilitation Seattle, Washington Associates in Milwaukee. In addition, he is an attending physiatrist at both Dr. Saeed received his specialty training in physical medicine and rehabil- St. Joseph’s Regional Medical Center and St. Michael’s Hospital in itation at the University of Washington in Seattle, Washington. Following Milwaukee as well as an attending physiatrist at Elmbrook Memorial residency, he served in the United States Army at Madigan Army Medical Hospital in Brookfield, Wisconsin. He performed a physical medicine and Center in Tacoma, Washington, and from 1981-1982 as Chief of the rehabilitation residency at the Rehabilitation Institute of Chicago and went Physical Medicine Service. For the past 20 years, he has been in private on to perform a fellowship in electrodiagnostic medicine at the Medical practice, now as senior partner with Electrodiagnosis and Rehabilitation College of Wisconsin. Dr. Park is board-certified by the Amercan Board of Associates of Tacoma. He has published several articles and abstracts on a Electrodiagnostic Medicine (ABEM), the American Board of Physical broad range of electrodiagnostic topics. Current clinical interests include Medicine and Rehabilitation, and the National Board of Medical lower extremity entrapment neuropathies, particularly focal neuropathies Examiners. He is an active member of the Association of Academic of the foot and tarsal tunnel syndrome. Dr. Saeed has often been invited Physiatrists and the AAEM. He has served on AAEM’s Education faculty at the AAEM annual meetings and has actively been involved on Committee and has been an oral examiner for the American Board of the Education, Workshop, Training Program, and Program Committees. Electrodiagnostic Medicine. He is also a manuscript reviewer for the He is a long time fellow of both the AAEM and AAPM&R, and has been Archives of Physical Medicine and Rehabilitation. an examiner for the American Board of Electrodiagnostic Medicine for many years. David R. Del Toro, MD Associate Professor Atul T. Patel, MD, MHSA Department of Physical Medicine and Rehabilitation Physiatrist Medical College of Wisconsin Kansas City Bone and Joint Clinic Milwaukee, Wisconsin Kansas City, Missouri Dr. Del Toro earned his medical degree at Indiana University School of Dr. Patel earned a bachelor of science in chemical engineering at the Medicine and performed an internship in general surgery at Methodist University of Houston before entering medical school at Baylor College of Hospital of Indiana in Indianapolis. He then performed a residency in Medicine. He then studied rehabilitation medicine at the University of physical medicine and rehabilitation at the Medical College of Wisconsin, Washington and later became Residency Program Director for the and is now an associate professor there. He is a member of several societies, Department of Rehabilitation Medicine at the University of Kansas including the American Academy of Physical Medicine and Rehabilitation Medical Center. He is currently a physiatrist at the Kansas City Bone and (AAPMR) and the AAEM. Dr. Del Toro has served on the AAEM’s Tarsal Joint Clinic in Kansas City. Dr. Patel is board-certified by the American Tunnel Syndrome Task Force, Young Physicians Task Force, and the Board of Physical Medicine and Rehabilitation (ABPMR), ABPMR sub- AAEM Workshop Committee. He is also an oral examiner for the speciality of spinal cord injury medicine, the American Board of American Board of Electrodiagnostic Medicine. Dr. Del Toro has also been Independent Medical Examiners, and the ABEM. He is a member of an abstract reviewer for AAPMR and is currently a manuscript reviewer for several professional organizations, including the American Academy of the Archives of Physical Medicine and Rehabilitation. Physical Medicine and Rehabiliation, the Association of Academic Physiatrists, the American Geriatric Society, and the American Academy of Disability Evaluating Physicians. He is also active in the AAEM, and has been the chair of the Tarsal Tunnel Task Force and a member of the Workshop, Program, and the Quality Assurance committees. Dr. Patel re- cently earned his Master of Health Services Administration degree. Course Chair: Tracy A. Park, MD The ideas and opinions expressed in this publication are solely those of the specific authors and do not necessarily represent those of the AAEM. AAEM Course Painful Foot and Ankle iii Mark E. Easley, MD Assistant Professor Division of Orthopaedic Surgery Duke University Medical Center Durham, North Carolina Dr. Easley is currently an assistant professor in the Division of Orthopaedic Surgery at Duke University Medical Center. He is also a consultant to several area medical centers. Dr. Easley attended medical school at the University of Virginia and went on to perform a foot/ankle fellowship at Union Memorial Hospital in Baltimore and a knee fellowship at Insall- Scott-Kelly Institute in New York. He is a member of the American Academy of Orthopaedic Surgeons, the Eastern Orthopaedic Association, and the American Orthopaedic Foot and Ankle Society, among others. In 2003, Dr. Easley was chosen as the American Orthopaedic Association’s ABC Traveling Fellow. Authors had nothing to disclose. Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for the spe- cific use described by the authors and are “off-label” (i.e., a use not described on the product’s label). “Off-label” devices or pharmaceuticals may be used if, in the judgement of the treating physician, such use is medically indicated to treat a patient’s condition. Information regarding the FDA clearance status of a particular device or pharmaceutical may be obtained by reading the product’s package labeling, by contacting a sales representative or legal counsel of the manufacturer of the device or pharmaceutical, or by contacting the FDA at 1-800-638-2041. iv AAEM Course v Painful Foot and Ankle Contents Faculty ii Objectives v Course Committee vi Peroneal Nerve Entrapments: Deep and Superficial 1 Tracy A. Park, MD Baxter’s Nerve Entrapment 9 David R. Del Toro, MD Tarsal Tunnel Syndrome 17 Mohammad A. Saeed, MD, MS Nonneurogenic Causes of Foot Pain 27 Atul T. Patel, MD, MHSA Surgical Management of Entrapment Neuropathies in the Foot, Including Indications and Outcomes 33 Mark E. Easley, MD CME Self-Assessment Test 53 Evaluation 55 Future Meeting Recommendations 57 O BJECTIVES—After attending this course, the participant will be able to (1) discuss the anatomy of the foot as it relates to entrapment of, and electrodiagnostic study of, the terminal branches of the tibial nerve, deep peroneal nerve, and superficial peroneal nerve, (2) discuss the anatomy of the foot as it relates to common non-neurogenic causes of foot pain, (3) discuss the clinical presentation and differential di- agnosis of tarsal tunnel syndrome, Baxter’s nerve entrapment, “anterior” tarsal tunnel syndrome, and superficial peroneal nerve entrapment, (4) devise and perform an electrodiagnostic examination that effectively addresses suspected isolated nerve entrapments in the foot, and (5) discuss the surgical and nonsurgical approaches to the management of neurogenic and nonneurogenic foot pain. P REREQUISITE—This course is designed as an educational opportunity for residents, fellows, and practicing clinical EDX consultants at an early point in their career, or for more senior EDX practitioners who are seeking a pragmatic review of basic clinical and EDX prin- ciples. It is open only to persons with an MD, DO, DVM, DDS, or foreign equivalent degree. A CCREDITATION S TATEMENT—The AAEM is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education (CME) for physicians. CME CREDIT—The AAEM designates attendance at this course for a maximum of 3.5 hours in category 1 credit towards the AMA Physician’s Recognition Award. This educational event is approved as an Accredited Group Learning Activity under Section 1 of the Framework of Continuing Professional Development (CPD) options for the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Each physician should claim only those hours of credit he/she actually spent in the activity. The American Medical Association has determined that non-US licensed physicians who participate in this CME activity are eligible for AMA PMR category 1 credit. vi 2003-2004 AAEM COURSE COMMITTEE Kathleen D. Kennelly, MD, PhD Jacksonville, Florida Thomas Hyatt Brannagan, III, MD Dale J. Lange, MD T. Darrell